1. Wellness Recovery Teams – An Innovative Approach to Integrated Health Homes for Individuals with SMI LeeAnn Moyer, Deputy Administrator of Behavioral Health Montgomery County Department of Behavioral and Developmental Disabilities DBHIDS Health Care Integration in Philadelphia June 25, 2013

2. Pennsylvania Serious Mental Illness (SMI) Innovation Project In 2008, the Center for Health Care Strategies (CHCS) launched a multi-state, national effort to improve quality and reduce expenditures for Medicaid beneficiaries with complex medical and behavioral health needs Pennsylvania was among the states selected to participate in the effort SE Project Name: HealthChoices HealthConnections (HCHC) 2

3. Pennsylvania Serious Mental Illness (SMI) Innovation Project SE Project Partners Department of Public Welfare Mathematical Policy Research and IPRO Center for Health Care Strategies Bucks, Montgomery and Delaware Counties Magellan Behavioral Health of Pennsylvania, Inc. Keystone Mercy Health Plan 3 Partner Vision Group Meeting

4. Criteria for Inclusion Ages 18+ Diagnosis of Schizophrenia (295.XX) Diagnosis of a Mood Disorder (296.XX) Diagnosis of Borderline Personality Disorder (301.83) Program is voluntary and individuals may opt-out Consent needed to release and share information (includes MH, Substance Abuse (SA) and HIV-related information) 4

5. Program Goals and Objectives Improve Health for Members Decrease gaps in care for behavioral and medical conditions Improve the rate of medication adherence Improve the rate of preventive services Improve the rate of visits with providers Reduce avoidable hospital admissions and emergency room visits Improve Member Satisfaction Better access and services Improved coordination of care 5

6. Pennsylvania SMI Innovations Project Intervention Pillars Coordination of hospital discharge & appropriate follow-up Pharmacy management Co-location of resources Focus on appropriate Emergency Department use for Behavioral Health (BH) treatment Focus on alcohol and substance abuse treatment/care coordination Consumer engagement Data management and information exchange Provider engagement/medical home 6

7. Montgomery County Project Scope and Funding Total Consenting Member: 367 Five Agencies and Two ACT Teams 2009-2010: Funded with Reinvestment 2010: OMHSAS approved service description; HealthChoices funding effective October 1, 2010 Funding: Per member per month case rate 7

8. Plan Level Interventions: Member Profile Unique marriage of data between two independent health plans Magellan and Keystone Mercy Health Plan Demographics Primary Care Provider (PCP) and BH provider contact information Physical Health (PH) and BH diagnoses Service utilization of specialists PH and BH levels of service and claims information Hospitalizations; ER visits; BH Crisis Service Pharmacy data Gaps in routine physical health screenings/evaluations Includes D/A and HIV information 8

9. Plan Level Interventions Easy access with plan-based case coordinators to collaborate on the special needs of member Notify of BH & PH Hospitalization Recommend referrals as appropriate Pharmaceutical Management Access to BH & PH educational material Joint Case Rounds (Includes plans’ case coordinators, plans’ physician advisors, Wellness Recovery Team and other healthcare participants, as needed) 9

10. Provider Level Interventions: Wellness Recovery Team (WRT) Team of Navigators: RN, masters level MH or BH Professional, Administrative Navigator *Completed approved integrated PH/BH certification Phased approach to interventions with the goal of self-management 10 Member with her WRT and Magellan HCHC Community Support Partner

11. Provider Level Interventions: Wellness Recovery Team (WRT) Outreach and Engagement Therapeutic alliance with WRT Utilize Member Profile as tool to coordinate care Assist member in creating individual Wellness Plan Identification of “virtual team” supports-relationship building Community-based, mobile 11 Member reviewing her Wellness Plan with RN Navigator and Therapist

12. Provider Level Interventions: Wellness Recovery Team (WRT) Notification of BH & PH hospitalization Discharge planning and coordination Linkage to community supports Referrals as appropriate 12 Triage and planning by WRT and RN

13. Provider Level Interventions: Wellness Recovery Team (WRT) Joint Case Rounds Develop and maintain an ongoing relationship with a PCP and Psychiatrist Pharmacy consultation and collaboration Co-occurring substance use screening and treatment interventions Trauma-informed and Motivational interventions Preventive care 13 WRT consultation with Psychiatrist

14. Provider Level Interventions: Wellness Recovery Team (WRT) Continuity of relationships over time; immediate re-engagement if needed Wellness groups BH and PH wellness checks Provide educational material Collaborative care management activities are billable 14 Member monitoring her wellness goal

15. Advantage of Multi-Level Approach to Coordination PH plan to BH plan to WRT Coordination between WRT and PCP Creating a “virtual team” Specialist coordination Achieving financial efficiencies 15

16. HealthChoices HealthConnections Cost Impact Study Selection of Population Members Consented for Participation in HealthChoices HealthConnections (HCHC) Members Anchored in the Wellness Recovery Team (WRT) 137 Members identified as having active participation in the WRT program as of November 30, 2010 Measurement Periods 6 Months prior to participation (anchor date) in WRT 6 Months during participation (anchor date) in WRT 16

17. 17 The change found in individuals’ use of treatment in 24 hour settings and Emergency Rooms while participating in HCHC is substantially diminished compared with such need prior to HCHC involvement. The need for emergency care in a medical facility ER decreased by 11% Admissions to medical facilities reduced by 56% Admissions to psychiatric hospitals reduced by 43% The need for an assisted residential environment declined by 14% The support and proactive coordination of services and wellness activities found with the HCHC approach has resulted in a reduced need for these high level and often invasive interventions. HealthChoices HealthConnections Cost Impact Study

18. Continuous Quality Management: Monthly Learning Collaborative Ongoing learning by sharing of collective experiences and challenges Development and spread of promising practices and strategies Network, relationship development and information/resource exchange Identify and meet education and training needs 18 Learning Collaborative

19. Continuous Quality Management: Onsite Meetings with Each Provider Provide Technical Assistance Implementation of the Consumer Health Inventory (CHI) Tool Conduct Quality Initiatives Collaboratively Monitor Program 19 Member completing a CHI

20. Continuous Quality Management: Administration of the Consumer Health Inventory (CHI) 20 Domain % of HCHC Members Reporting Progress % of All Magellan PS Members Reporting Progress Behavioral Symptoms29.03%21.57% Strength38.71%32.62% Provider Relationship80%33.30% Work-School Participation22.58%6.20% Domain% of Members with Improvement % of All Magellan PS Members with Improvement Emotional Health58.06%38.05% Physical Health54.84%35.16%

21. Continuous Quality Management: Consumer Satisfaction Surveys Active involvement with HCHC Consumer Advisory Board Member Surveys conducted by Consumer Satisfaction Team Peer Specialist involvement with Quality Improvement activities 21 Consumer Advisory Board Members (Person in Recovery, Certified Peer Specialist, and Montgomery County QI Coordinator )

22. Continuous Quality Management: Consumer Satisfaction Surveys 22

23. Continuous Quality Management: Consumer Satisfaction Surveys 23

24. Continuous Quality Management: Consumer Satisfaction Surveys 24

25. Where Are We Today Current census 380 adults Working on Protocol to share PH/BH data with DPW Expansion of Health Homes by Adding RN services in Outpatient Magellan Behavioral Health enhanced their website to promote Mobile Access to website by Navigators and Consumers; Introduced a new tool- Health & Wellness Questionnaire

26. Montgomery County HealthConnections: Wellness Recovery Teams were selected as a promising innovative model by the Medicare- Medicaid Coordinating Office (MMCO) in 2012 Montco recognized for the wide array of community based supportive services; housing initiatives and evidence based practices